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| Enroll as a World Payment Services Agent |
| Username |
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| Password |
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![header=[Password] body=[Must be at least 4 characters in length and not more than 12 characters in length. It may only contain letters, numbers and underscores.]](https://www.worldpaymentservices.com/members/images/help.gif) |
| Password Again |
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![header=[Password Again] body=[This entry must match the Password entry.]](https://www.worldpaymentservices.com/members/images/help.gif) |
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| Standard Information |
| Email Address |
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| Company Name |
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| Personal Information |
| First Name |
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City, State, Zip | |
| Last Name |
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Phone Number | |
| Address |
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Fax Number | |
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Country |
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| Terms and Conditions |
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| I have read, understand and agree to the above terms and conditions. |
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| User Defined Fields |
| How did you hear about us? | |
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| Enrollment Verification |
| Please enter the security code shown in the box. This step helps us to prevent automated signups. |
| Security Code |
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